Chapter 30
Head and Neck Cancer
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This chapter refers to those tumors of an epithelial character arising from the mucosal lining
of the aerodigestive tract. The most common sites of the aerodigestive tract affected are the
oral cavity, pharynx, paranasal sinuses, larynx, thyroid gland, and salivary glands.
Reducing the deformity, maintaining the reduction, and restoring the function are essential to
the management of head and neck cancer.
Treatment that causes the permanent loss of vision, smell, taste, or hearing should be
evaluated concerning its effect on quality of life and survival.
With early detection techniques, head and neck cancers involving the larynx and other upper
aerodigestive sites treated by radiation therapy allow for preservation of voice and
swallowing.
Today, only one third of affected patients present at an early disease stage.
An estimated two thirds of patients present with locally advanced disease, either at the
primary site or in the cervical lymph nodes, stages III and IV.
The lungs are the most common site of distant metastasis.
Other sites of distant metastasis include the mediastinal lymph nodes, liver, brain, and bones.
The incidence of distant metastasis is greatest with tumors of the nasopharynx and
hypopharynx.
Tumors may spread along the nerves, direct nerve invasion may occur from tumors in the
affected area
High-grade parotid tumors are known to involve the facial nerve and to cause paralysis.
The standard treatment for these patients is either surgery with preoperative or more
commonly postoperative radiation therapy or is primary radiation therapy followed by
surgery.
Epidemiology
 Head and neck cancers account for approximately 5% of the overall incidence of cancer in
the United States and 2% of cancer deaths.
 Occur mostly in men from the age of 50- 60s
 Cancers of the nasopharynx and hypopharynx are extremely common in India and China
due to environmental factors
 Tumors of the oral cavity and base of tongue (50% of all cancers) are more common in
India owed to the chewing of pan, a mixture of betel leaf, lime catechu and areca nut; the
alkaloids released when the nut is chewed provoke excessive and abnormal synthesis of
collagen by cultured fibroblasts causing submucous fibrosis.
 Recurrences usually occur within the first 2 years and rarely after 4 years.
 For all stages, the 5-year survival rate for oral cavity and pharynx is 55%.
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Etiology
 Unfiltered cigarettes cause lip carcinoma, especially when habitually held in the same place.
 Smoking, tobacco and alcohol: this combination has been regarded as the most important
risk factor for this disease.
 Alcohol seems to have a synergistic effect on the carcinogenic potential of tobacco.
 Chewing tobacco causes squamous cell carcinoma of cheek and gum.
 Leukoplakia: premalignant lesions; thick, white, patches on the mucous membrane that
are slightly raised and should be removed.
 Exposure to UV is a risk factor for the development of lip cancer
 Occupational exposures: occupations associated with greater risk include nickel refining
(laryngeal cancer), furniture and woodworking (cancers of the nasal cavity and paranasal
sinuses) and steel and textile workers (oral cancer).
 Nasopharyngeal cancer has been linked to the Epstein Barr virus
 The Plummer-Vinson syndrome (esophageal web, iron deficiency anemia, dysphasia from
glossitis) is associated with a high incidence of postcricoid and tongue carcinoma: fruits,
vegetables, and carotenoids may have a preventive role.
 Dentures and poor oral hygiene: some carcinomas develop in areas covered by or adjacent
to a prosthetic appliance: chronic denture irritation may possibly promote neoplastic activity.
Prognostic indicators:
 Leukoplakia: premalignant lesions, higher incidence in tobacco users; thick, white,
patches on the mucous membrane that are slightly raised.
 Erythroplasia: red velvety patches 80% contain carcinoma in situ (biopsy required)
 The morbidity of treatments increases and the prognosis decreases as the affected area
progresses backward from the lips to the hypopharynx, excluding the larynx.
 Lesions that cross the midline, exhibit endophytic growth (invasion of the lamina propria
and submucosa), have cranial nerve involvement, have fixed nodes or a fixed lesion in the
anatomic compartments, are poorly differentiated, and are nonsquamous cell cancers
represent advanced growth and have an unfavorable prognosis.
Anatomy
 C1: lies at the inferior margin of the nasopharynx
 C2-C3: at the level of the oropharynx
 C3 epiglottis
 C4: the true vocal cords
 Laryngopharynx is a part of trachea
 Oral cavity stops at the soft palate
Lymphatics:
 Nearly one third of the body’s lymph nodes are located in the head and neck area,
common way for spread for head and neck cancers.
 Because a metastatic cervical lymph node is clinically present in many of the tumors found in
the head and neck area, an assessment of node involvement dictates the size of the radiation
portal and the treatment plan.
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The jugulodigastric group is also called the subdigastric node (the group of neck nodes
below the mastoid tip) receives nearly all the lymph from the head area and is usually
treated
The retropharyngeal node- aka the Rouviere node- behind the pharynx- is included as the
minimum target volume for nasopharyngeal cancer.
The spinal accessory chain is also called the posterior cervical lymph node.
Cervical nodes (including internal jugular) are positive for tumor in 6% to 23% of cases
for nasopharyngeal cancer- the supraclavicular area requires prophylactic treatment.
other nodes: submaxillary, submental, preauricular and facial
More than 75% of all head and neck cancers recur locally or regionally
NPC has chance of bloodborne distant spread first to the bone and then to the lung.
Clinical presentation:
 Endophytic: grows into epithelium, more aggressive and harder to control
 Exophytic: noninvasive neoplasms, characterized by raised elevated borders.
 Common symptoms by site
 Oral cavity: swelling or an ulcer that fails to heal
 Oropharynx: painful swallowing and referred otalgia
 Nasopharynx: bloody discharge and difficulty hearing
 Larynx: hoarseness and stridor
 Hypopharynx: dysphagia and painful neck node
 Nose and sinuses: obstruction, discharge, facial pain, diplopia, and local swelling
 Common clinical presentations by site
 A high cervical neck mass often represents metastases from the nasopharynx
 Positive subdigastric nodes are often the site of metastases from the oral cavity,
oropharynx, or hypopharynx
 Positive submandibular triangle nodes arise from the oral cavity
 Midcervical neck masses are associated with tumors of the hypopharynx, base of
tongue and larynx
 Preauricular nodes frequently arise form tumors found in the salivary glands.
Detection and diagnosis:
 Careful examination and inspection of the head and neck via indirect laryngoscopy,
palpation, and fiberoptic endoscopy are of paramount importance.
 Nodes that are hard, greater than 1 cm, nontender, nonmobile, and raised probably contain
metastatic disease.
 CT, MRI, and x-ray examinations of the skull, sinuses, and soft tissue
 Radiograph of the chest and bone scans to rule out metastases
 PET may be useful in locating occult tumor in situations of an unknown primary and in
ascertaining tumor recurrence after treatment.
 Anti-Epstein-Barr antibody titers are fairly specific for NPC.
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Pathology:
 More than 80% of head and neck cancers arise from the surface epithelium of the mucosal
linings of the upper digestive tract, these cancers are mostly squamous cell carcinomas,
squamous cell carcinomas seen in the head and neck region include:
 Lymphoepithelioma: occurs in places of abundant lymphoid tissue
 Spindle cell carcinoma: has a nonneoplastic background and responds to radiation
therapy in much the same manner as squamous cell carcinoma
 Verrucous carcinoma: most often found in the gingival and buccal mucosa: indolent
pattern of growth and is associated with chewing tobacco or snuff: tends to be exophytic,
have distinct margins, and look like warts
 Undifferentiated carcinoma:
 Adenocarcinomas are found to a lesser extent in the salivary glands
 Grade:
o G-1: well differentiated
o G-2: moderately well differentiated
o G-3: poorly differentiated
Staging:
TNM
T: varies with each anatomic site and are size oriented.
Glottic larynx:
 T1: confinement to true vocal cords; normal mobility; includes anterior or posterior
commissure (radiation)
 T2: supraglottic or subglottic extension; normal or impaired mobility (radiation)
 T3: confinement to larynx proper; cord fixation (larygectomy)
 T4: cartilage destruction and/or extension out of larynx (laryngectomy)
N: are uniform for all sites, except for the thyroid, the sizes and locations of dosed determine the
N designation.
 NX: nodes cannot be assessed
 N0: no clinically positive nodes
 N1: single, clinically positive, ipsilateral node; < or = 3 cm
 N2a: single, clinically positive, ipsilateral node; > 3 or = 6 cm
 N2b: multiple, clinically positive, ipsilateral node(s) all < or = 6 cm
 N3a: clinically positive, ipsilateral nodes; one > 6 cm
 N3c: contralateral, clinically positive node(s) only
Stage grouping:
 Stage I: T1 N0 M0
 Stage II: T2 N0 M0
 Stage III: T3 N0 M0, T1 T2, or T3 N1 M0
 Stage IV: T4 N0 or N1 M0
Any T N2 or N3 M0
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Radiation and surgery are the major curative modalities.
Spread: lymphatic and direct extension
o Blood: parotid and NPC
Radiation therapy is indicated in most head and neck cancers because the tumors located in
this region are often inaccessible to the surgeon’s knife.
Surgery:
 The use of surgery as a curative modality is correlated to the possibility of an en-block
resection (whole tumor).
 Partial resections involve a high risk of recurrence
 Wide margins (> 2 cm) are usually necessary
 Surgery is the mode of treatment for early stage lesions of the oral cavity and floor of the
mouth, if no nodes are clinically positive for tumor or if the risk of deep cervical node
involvement is low.
 Surgery reduces the risk of dental or salivary deficiencies
 Laser therapy, cryotherapy and electrocautery are conventional curative surgical modalities.
 Surgery has a higher success rate for palliative salvage therapy in the event of failure after
radiation therapy.
 Reconstruction of the midface, the oral cavity including the mandible, the base of the tongue,
and the hypopharynx has made the plastic surgeon an essential member of the head and neck
disease management team.
Chemotherapy:
 The role of chemotherapy in head and neck cancer is standard for metastatic disease, locally
recurrent disease, or salvage therapy, for which surgery and radiation therapy can no longer
be used.
Radiation therapy:
 The use of radiation is considered the mainstay for the treatment of cancer in the head and
neck region
 The choice of external beam therapy and or brachytherapy depends on the individual and
location of the tumor.
 Brachytherapy (interstitial methods) are readily performed for small volume implants- use
iridium-192, iodine- 125, cesium or gold.
 Doses:
 Palliative doses are 4500 cGy in 4 ½ weeks
 Curative doses are given via a shrinking field technique
 The primary site receiving the highest dose and peripheral areas at risk for microscopic
tumor spread (including the neck nodes) receiving a lower dose but never less than 4500
to 5000 cGy, with total curative dose of 7000+ cGy.
 The delivery of radiation to areas in which the dose will exceed 7000 cGy is usually
accomplished with brachytherapy or electrons.
 Implant therapy is administered via seeds, ribbons, or needles that allow high concentration
doses to a small volume.
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Areas that are clinically positive for tumor and areas with suspicious microscopic findings in
the margins determine the port size and shape
Neck nodes that are positive for tumor and any nodes believed to harbor subclinical
disease are included.
Hyperfractionation: 115 cGy twice a day to a total dose of 7000 to 8000 cGy- worse
morbidity.
Nodes:
 For neck nodes clinically negative for tumor, all patients receive 5000-5400 cGy
 If the neck nodes are clinically positive for tumor, the lateral ports are enlarged to
include all the upper cervical nodes, and an anterior, bilateral, supraclavicular neck
field is added.
 The supraclavicular field is taken to 5000 cGy, with off cord electron boosts of 1500
cGy added.
o Independent jaw blocks half the beam
 Lateral: treated with superior portion of beam
 Anterior: treated with inferior portion of beam
 No gaps: not accurate (not sure why)
THE ORAL CAVITY:
 The oral cavity extends from the skin-vermilion junction of the lip to the posterior border of
the hard palate superiorly and the circumvallate papillae inferiorly.
 Subdivisions within the oral cavity include the anterior two thirds of the tongue, lip, buccal
mucosa, lower and upper alveolar ridges, retromolar trigone, floor of mouth and hard
palate
 Oral cavity cancers, the most common aerodigestive tract carcinomas, occur mostly (80%)
in men between the ages of 55 and 65, alcohol and tobacco have a synergistic etiologic
history.
 Patients who have oral cavity cancer often demonstrate poor oral and dental hygiene
 In females, Plummer Vinson syndrome(iron deficiency anemia)
 Leukoplakia and erythroplasia (a premalignant well-circumscribed reddish patch) represent
severe dysplastic changes
 Oral cavity cancers appear as nonhealing ulcers with little pain.
 Squamous cell carcinoma accounts for 90 to 95% of the histopathologic types, either well
or moderately well differentiated
 Cervical lymph node involvement at the time of presentation is uncommon.
 Treatment:
 Early stage (< 1 to 1.5 cm) and premalignant lesions are candidates for surgery alone.
 Lip:
 Lip cancer is treated with radiation in the same manner as skin cancer
 External beam therapy, interstitial implants or both
 To reduce dose to teeth and gums, a stent coated with wax or a low atomic number
compound (tissue equivalent) can be made to fit over the teeth
 A stent is a lead shield that may consist of two sheets of lead overlain with one sheet of
aluminum and is coated with wax or vinyl.
 The expected 5-year survival rate is 85%
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 Floor of mouth
 Cancers in this area arise on the anterior surface on either side of the midline
 They can spread to the bone and tongue
 About 30% of these cancers have involvement of submaxillary and subdigastric nodes
 Also included are the cervical and supraclavicular
 Opposed lateral ports are used
 If the lesion is small and confined to the floor of the mouth, the tip of the tongue is
elevated out of the portal with a cork or a bite block and tongue depressor (tongue blade)
 Bite blocks may also serve to spare the roof of the mouth from incidental irradiation.
 Tongue:
 Only the anterior two third is included in the oral cavity.
 Small tumors arising in the anterior two thirds of the tongue also known as the oral
tongue are usually resected.
 Hemiglossectomy: surgical removal of half the tongue- early stage
 Lesions of the tongue usually appear on the lateral borders near the middle and
posterior third section
 External beam irradiation can achieve the best control
 A depressor is sometimes inserted to push the tongue back and keep as much of the
mandible out of the field as possible.
 Lesions at the base and posterior one third of the tongue invade the floor of the mouth,
the tonsils, or the muscles; are advanced; and have a higher incidence of nodal metastasis
 External beam irradiation is the best choice for large T3 to T4 lesions: iridium-192
implants follow the external beam
 The subdigastric and submaxillary nodes must always be included in the port with an
off cord boost after 4500 cGy and an anterior supraclavicular field.
 Buccal Mucosa
 The buccal mucosa is the mucous membrane lining the inner surface of the cheeks and
lips
 Most lesions originate on the lateral walls; have a history of leukoplakia; and appear as a
raised, exophytic growth
 As it grows, the lesion invades the skin and bone.
 If radiation therapy is chosen as a treatment modality, a single plane photon or electron
beam that spares contralateral tissues can be used.
 Hard palate:
 The hard palate is the semilunar area between the upper alveolar ridge and the mucous
membrane covering the palatine process of the maxillary palatine bones.
 Hard palate carcinomas are rare and are mostly adenocarcinomas.
 They tend to spread to the bone and invade the maxillary antrum
 Retromolar trigone:
 The retromolar trigone is the triangular space behind the last molar tooth.
 Lesions can cause tongue pain, ear canal pain, or if the muscles become involved,
trismus.
 Can spread to maxillary sinus.
 Surgery preferred but can be disfiguring.
 A 5-year determinate survival rate of 83% has been reported.
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THE PHARYNX:
 The pharynx is subdivided into three anatomic divisions the oropharynx, nasopharynx and
hypopharynx
 Clinical presentation: the most common symptoms include persistent sore throat, painful
swallowing, and referred otalgia
 Enlargement of cervical nodes
 Inspection includes mirror examination (essential), palpation, biopsy (essential).
 Predominately squamous cell carcinomas
 The incidence of bilateral neck disease is up to 40%.
 Radiation preferred treatment.
 Oropharynx
 The oropharynx consists of the base of the tongue, the tonsils, the soft palate, uvula,
and the oropharyngeal walls
 The oropharynx is situated between the axis and the C3 vertebral bodies.
 The tonsils are the most common site of disease
 Clinically a sore throat and pain during swallowing are the most common presenting
symptoms
 Early T1 to T2 lesions are treatable with external beam irradiation alone.
 Large ports are required for T3 to T4 lesions that encompass the cervical and
supraclavicular neck nodes.
 The preference is neck dissection for palpable nodes
 Hypopharynx
 The hypopharynx is composed of the pyriform sinuses, postcricoid, and lower posterior
pharyngeal walls below the base of the tongue
 It is anatomically situated between the vertebral bodies C3 to C6
 The cricoid cartilage represents the inferior border, and the epiglottis is the superior
border.
 The pyriform sinus is the site of highest incidence of hypopharyngeal cancer.
 Care must be taken to ensure that the shoulders are pulled down toward the feet and
remain that way during treatment.
 The lateral retropharyngeal and jugular chain nodes are treated, even if they are clinically
negative for tumor
 Substantial soft tissue, cord damage, airway damage, or fibrosis is possible with these
fields if the radiation dose to the critical organs is not carefully monitored
 5-year survival rates greater than 70% has been reported for early lesions
 Most cases are advanced and overall survival rarely exceeds 25%
 Nasopharynx:
 The nasopharynx includes the posterosuperior pharyngeal wall and lateral pharyngeal
wall, the Eustachian tube orifice and adenoids, lies on a line from the zygomatic arch
to the external auditory meatus (EAM), extending inferiorly to the mastoid tip,
 The nasopharyx lies behind the nasal cavities and above the level of the soft palate.
 Disease of the nasopharynx can mimic an inflammatory process and cause
considerable respiratory or auditory dysfunction.
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Because of its proximity to the base of the brain a lesion can directly include the
cranial nerves
Any cranial nerve involvement signifies advanced, widespread disease.
90% of these lesions are squamous cell carcinomas.
This disease is not associated with tobacco consumption.
NPC is associated with the Epstein Barr virus and the age distribution is bimodal, with
a small peak in adolescence and young adulthood and the major peak occurring
between 50 and 70 years
The disease is uncommon in white populations (2% in U.S.)
There is a high incidence in southern china (57%)
o nitrosamines in fish
75 to 85% of NPC patients have cervical nodes that are clinically positive for tumor,
with about half of all cases having bilateral or contralateral disease.
The lateral retropharyngeal, which usually cannot be surgically removed, and
jugulodigastric nodes are nearly always treated as tumor volume as well as the
cervical and supraclavicular.
25% chance of developing a blood born distant metastasis with bone and lung being
the most common sites.
30% to 40% local recurrence rate- aggressive large volume curative radiation therapy
necessary
Opposing laterals with a matching anterior supraclavicular field.
Concomitant chemotherapy should be used along with radiation for stage III and IV
(localized) tumors.
This disease has an overall 45% survival rate.
LARYNX
 Extends from the tip of the epiglottis at the level of the lower border of the cricoid cartilage
at the level of the C6 vertebrae.
 The larynx is subdivided into three sites the glottis (65%), supraglottis (30%), and subglottis
region
 Cancers of the larynx are the most common cancers of the upper aerodigestive tract
 Carcinomas of the glottis (true vocal cord) are not considered life threatening
 Larynx cancer is mostly 90% a male dominated disease, with a peak incidence in the 50 to
60 year age group
 Laryngeal carcinomas display an extremely high association with smoking
 The use of black tobacco is associated with a higher risk
 Mutation of the p53 gene is common
 A persistent sore throat and hoarseness are classic presenting symptoms,
 Cervical lymph node involvement, if present is seen in supraglottic lesions but not in glottic
lesions
 Carcinoma in situ is common on the vocal cords
 Glottic lesions are well to moderately differentiated with supraglottic lesions being less
differentiated and more aggressive
 About 65% to 75% of glottic lesions appear on the anterior two thirds of one cord.
9
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Radiation therapy is the primary choice of treatment for nonfixed surface lesions that have
not extensively infiltrated muscle, bone or cartilage
Glottic cancer is treated with opposing lateral fields, 5 x 5 cm (for T1 and early T2) to 6 x
6 cm
Wedges are indicated if the tissue inhomogeneities produce unacceptable hot spots in the
posterior margins
Daily doses can be 200 to 220 cGy up to a total dose of 6000 to 7000 cGy.
Large fixed lesions need more aggressive therapy
Field borders are:
 Superior: top of hyoid bone
 Inferior: cricoid cartilage
 Anterior: 1 to 1 ½ cm shine over (flash)
 Posterior: just anterior to the vertebral body
Survival rates are good for glottic cancer: 80% to 90%
SALIVARY GLANDS: rare
 Any tumor of the salivary glands can involve lymphatics, major cranial nerves, and arterial
neck blood flow: tumors in this area can cause facial paralysis, nerve pain, and interruption
of the neck muscles blood supply.
 The salivary glands consist of three large paired, major glands- the parotid, submandibular,
and sublingual glands.
 The parotid gland is the largest of the three salivary glands
 Of these tumors, nearly 2/3 are benign, though recur and block salivary gland production.
 Tumors of the minor salivary glands 75% malignant
 The more common cell types for malignant tumors are adenoid cystic, mucoepidermoid,
and adenocarcinoma
 Most patients develop an asymptomatic parotid mass lasting on average from 4 to 8 months
before presentation
 Presenting symptoms are localized swelling and pain, facial palsy, and rapid growth
 Facial nerve involvement is highly suggestive of a malignancy
 A diagnosis via a lobectomy is done
 Tumors in this area are mostly benign, the risk of local recurrence is high
 They are treated as low grade cancer and are optimally treated via total resection, with
generous margins for sparing facial nerves
 Radiation therapy is given postoperatively for residual, recurrent or inoperable lesions
5000 to 7000 cGy
 Tumors are unilateral- the opposite side is seldom at risk.
 A strip of bolus should be placed over the scar to raise the surface dose and prevent
recurrence in the scar.
 The neck nodes are included without the anterior supraclavicular field.
 Neutron therapy has been used, though no long-term difference.
 The target volume is commonly designed to fit the local invasion and lymphatic spread
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MAXILLARY SINUS
 The maxillary sinus is a pyramid shaped cavity lined by ciliated epithelium and bound by
thin bone
 Carcinomas arising from the ciliated epithelium or mucous glands perforate the bony walls
almost from the start
 Tumors involving the superior portion of the sinus readily extend into the orbit
 Maxillary sinus disease accounts for 80% of all sinus cancers
 Patient with this type of cancer have a history of ling standing sinusitis, nasal obstructions
and bloody discharge.
 These cancers are mostly squamous cell carcinomas and tend to invade the floor of the orbit,
ethmoid sinuses, hard palate, and zygomatic arch,
 Displacement of the eye is common.
 Cervical nodal spread is uncommon, but, if it is present, the submandibular node is the first
station involved and will be treated.
 Surgery is the principle treatment for control of small lesions or to debulk larger lesions.
 Primary radiation has a significant chance of optic nerve injury from the high dose
required to achieve good tumor control.
 A classic technique for radiation therapy involves preoperative doses of 6000 cGy, which are
delivered via an external beam. Wedged pair technique.
 Dose limiting structures include the optic nerves, chiasm, eyes, lacrimal gland, pituitary,
brainstem, etc
 The 5-year survival rate is poor because of recurrent disease and invasion of the brain and
skull.
 An overall survival rate is typically 20 to 30%
MANAGEMENT
 Rapidly dividing cells are most sensitive and nondividing or slowly dividing cells generally
are less radiosensitive or radioresistant.
 Because healing is poor after treatment, the teeth should be extracted before radiation therapy
if the patient has carious teeth.
 Mucositis/stomatitis: 3000 cGy, the epithelial cells of the mucous membrane lining the oral
cavity are extremely radiosensitive. Inflammation of the oral mucous membranes with edema
and tenderness can occur
 Mouth care should involve avoiding drying agents, and brushing and rinsing the oral
cavity frequently.
 Xerostomia occurs after 1000 cGy to 2000 cGy and may be permanent after 4000 cGy
 Amaphostine (ethyel) is a radioprotector to protect the salivary glands, should be treated
with radiation within 30 minutes, side effect- reduces blood pressure.
 When the salivary glands are within the treatment fields, the saliva becomes scant and is
thick and ropy.
 In some patients, pilocarpine hydrochloride (Salogen) has been useful in stimulating the
production of saliva.
 Cataracts: 500- 1000 cGy
 Lacrimal glands: cause a dry painful eye, more than 5700 cGy
 The taste buds are radiosensitive: atrophy and degeneration is noted at 1000 cGy
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Skin: reactions range from mild erythema or dryness to dry or moist desquamation
 Moisturizing lotions and gels can be applied to areas of dry desquamation.
ROLE OF THERAPIST:
 Candida albicans (thrush): a yeast infection in the mouth caused by radiation killing the
natural flora. Appears suddenly, consult MD- patient will be prescribed an antifungal such as
Diflucan.
 Responsible for assessing the efficiency of the treatment in terms of the health and wellbeing of the patient
 Educate patient on side effects (site specific and dose dependant)
 Give patients explicit instructions regarding physical changes to look for in tissue color,
texture, new growth, or unexplained pain
 Soreness of the throat and mouth is expected to appear in the second or third week of
standard fractionated external beam therapy
 Lidocaine or oragel provide temporary relief
 Loss of saliva : sipping cool carbonated drinks during the day
 Instruct the patient about wound care.
TABLES:
Table 30-3
Approximate dose-tissue response schedule
For a conventional fractionation scheme
Response
Dose (cGy)
Dry mouth
2000
Erythema
2000
Brachial plexus
5500
Spinal cord
4500
Lhermitte’s sign
2000-3000
Mandible, teeth and gums 5000-6000
Mucositis
3000
Ears (NPC)
4000
Cataracts
500-1000
Dry eye
4000+
Optic nerve
5000
Retina
5000
Trismus
6000
Laryngitis
5000
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Doses allowed for special organs in
The head and neck region
Organ
TD5/5 (in cGy)
Muscles (adult)
6000
Oral cavity
6000
Spinal cord
4500
Lens of eye
500
Brain
6000
Retina
5500
Cornea
5000
Ear
5000
Thyroid gland
4500
Pituitary gland
4500
Typical curative radiation doses for head and neck lesions
5000 cGy
Nodes
5000 cGy
Any subclinical disease
6000 – 6500 cGy
T1 lesions
6500 – 7000 cGy
T2 lesions
7000 – 7500 cGy
T3 – T4 lesions
Box 30-10
Recommended oral-hygiene program and Nutrition
Clean teeth and gums daily with a soft tooth brush after meals
Use fluoride toothpaste or fluoride rinses daily
Floss daily
Rinse the mouth with salt and a baking soda solution (1 qt water, ½ Tsp
salt, ½ tsp baking soda)
See a dentist regularly during treatment for a teeth and gum
examination
To reduce the severity of any head and neck complication, the patient
should be encouraged to avoid the following:
**Spicy hot foods, course or raw vegetables, dry crackers, chips, and
nuts
**Smoking, chewing tobacco, and alcohol
**Sugary snacks
**Commercial mouthwash that contains alcohol because it dries the
mouth
**Cold foods and drinks
Box 30-11
Recommended skin care program
Wash the skin with lukewarm water, pat dry, and do not wash
off marks
Use mild soaps (e.g., Basis, Neutrogena)
Use water-based lotions or creams (e.g., Aquaphor, Eucerin)
Avoid lotions with perfume and deodorants
Avoid direct sunlight
Do not use straight razors
Avoid tight fitting collars and hat brims
Do not use aftershave lotions or perfumes
Apply only nonadherent, hydrophilic dressings to wounds
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